Healthcare Provider Details

I. General information

NPI: 1427014216
Provider Name (Legal Business Name): SOUTHERN HEART GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR SUITE 112
JACKSONVILLE FL
32207-8210
US

IV. Provider business mailing address

820 PRUDENTIAL DR SUITE 615
JACKSONVILLE FL
32207-8210
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-5996
  • Fax: 904-398-2480
Mailing address:
  • Phone: 904-398-0998
  • Fax: 904-398-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. PAUL H DILLAHUNT II
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 904-396-5996